Anxiety and depression among patient’s companions during admission to the ICU in the Omicron wave of COVID-19: A cross-sectional study in Aleppo University Hospital

Background After the COVID-19 pandemic, anxiety and depression have reached high levels, especially after the last wave, Omicron. Healthcare workers in contact with COVID-19 patients or those who come in contact with them may exhibit high levels of anxiety and depression. Therefore, we aimed to assess anxiety and depression symptoms among ICU companions of COVID-19 patients. Methods From 30 November 2021 to 1 March 2022, sixth-year medical students at Aleppo University Hospital conducted interviews with the companions of COVID-19 patients who they brought their patient to the ICU centre as part of a cross-sectional quantitative study using the PHQ-9 and GAD-7 tools to gauge their level of anxiety and depression among companions of COVID-19 patients. The data were analyzed using the SPSS program. In addition, logistic regression models were used to study possible factors of anxiety and depression symptoms during COVID-19. Results The total number was 997 participants in contact with COVID-19 patients. The mean score of the depression assessment tool (PHQ-9) in our questionnaire was 9.5 with a range of 0 to 27. At the same time, the anxiety assessment tool (GAD-7) had a mean score of 9.1, ranging from 0 to 21. A binary logistic regression was used to predict the relationship between depression and anxiety and various factors. We found that the companions with medical specialties were substantially less likely to develop anxiety than other companions [AOR = 0.459; 95%CI (0.23–0.9)], in addition females were substantially higher likely to develop depression than males [AOR = 1.322; 95%CI (0.992–1.762)]. 45.4% of companions had moderate to severe anxiety, in additon 50.8% of companions had moderate to severe depression. Conclusion Our research reveals that moderate to severe anxiety and sadness are present in roughly half of the COVID19 patients’ companions. Females, people with children, and hard workers were more inclined to feel anxious than others, and those who are not in the medical field were more likely to suffer from depression than others, thus it is critical to assist these groups during the present outbreaks (Omicron and Monkeybox).


Introduction
, also known as Coronavirus disease (COVID), was first identified in December 2019 in Wuhan, China, as a disease caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2) [1]. Even though COVID-19 is a new strain of coronavirus, it has been associated with illnesses ranging from the common cold to more severe ailments like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [1]. The Coronavirus infection causes symptoms such as fever, cough, chills, sore throat, nausea, myalgia, diarrhoea, and vomiting [2]. The risk of infection is higher for men with underlying diseases and may result in worse outcomes [2].
COVID-19 pandemic and the public health measures that followed it have been linked to higher rates of mental illness in general [3]. The virus outbreak led to various psychological effects on individuals, communities, nations, and even the entire world [4,5]. There may be a higher prevalence of the fear of death or illness, feeling helpless at an individual level than at a social level [6]. People's daily lives have been altered due to the COVID-19 pandemic, resulting in adverse mental health conditions like depression, anxiety, and stress(Depression is a mental condition characterised by chronic sorrow and lack of interest, Anxiety is a sense of discomfort that may range from minor to severe and includes concern or dread, and Stress is a typical bodily response to change that causes physical, emotional, and cognitive reactions.) [7]. Depending on the setting of the outbreak and the study population, COVID-19 infection is associated with varying mental health problems in the general population [8].
Coronavirus Disease 2019 (COVID-19) has profoundly altered social and working environments [9]. Policies of social distance, lockdowns, isolation periods, and anxiety about getting sick, along with suspensions of productive activity, income loss, and fear of the future, negatively impact the mental health of citizens and workers [10].
Mental health of people facing this pandemic scenario can be moderated or worsened by workplace factors [11]. Different occupations have been affected differently by the COVID-19 pandemic. As a result of close contact with infected patients, people accompanying Covid-19 patients during admission are more likely to become infected. Their psychological well-being and performance can be adversely affected by following COVID-19 protocols. Witnessing the suffering and death of patients often has a negative impact on this group's mental health [12]. Anxiety and/or fear associated with COVID-19 may also negatively affect healthcare job performance and job satisfaction, resulting in frequent absences from work and loss of income [13].
Identifying individuals in the early stages of psychological disorders such as fear, anxiety, depression, or insecurity improves the effectiveness of intervention strategies [14]. Hence, it is essential to establish purposeful mental health interventions early in Syria to address protective factors and the process of successful adaptation to adverse conditions. Individuals in direct contact with or accompanying patients with COVID-19 infection are at a greater risk of developing psychological disorders, so in this study, we want to assess the levels of anxiety and depression in Covid-19 patients' companions during the omicron wave at Aleppo University Hospital.

Study design
This study is a cross-sectional quantitative study based on an interview approach among companions of COVID-19 patients admitted to the ICU center at Aleppo university hospital from 30 November 2021 to 1 March 2022.

Objectives
This study aims to assess anxiety and depression in COVID-19 patients' companions during admission to the ICU.

Settings and participants
The target population was those who come with COVID-19 patients to the ICU center at Aleppo university hospital. Inclusion criteria included Syrian nationality, 18 years or older, willing to participate, and able to use the Internet. The exclusion criteria were under 18 years of age, major psychological disorders, and unwillingness to participate in the study.

Informed consent
Prior to the collection of data, informed consent was obtained electronically. We limited the age range for items such as age to individuals over 18 years of age, and we encouraged the respondents to carefully read the instructions before completing the survey. Overall, 997 participants completed the questionnaires, with the data analysis including all of them.

Demographic information.
The questionnaire consists of questions about age, gender, job, education level, marital status, and an additional question about chronic diseases.

Ethical approval
The study was carried out following the Declaration of Helsinki ethical standards and was approved by the Ethics Committee of Aleppo University Hospital. All participants provided electronic consent.

Data quality assurance and control
Utilizing paper-based questionnaires, data was gathered from the ICU division of the Aleppo University Hospital. The Cronbach alpha value for anxiety and depression, respectively, was determined to be 0.787 and 0.763 after a questionnaire's reliability and validity were examined. The flow, readability, and clarity of the questionnaire were also evaluated using a pretest, which was conducted on 20 participants but was excluded from the final data collection. Eleven data collectors (sixth-year medical students) and one supervisor (the president of the department of neurology at Aleppo University Hospital) were chosen for data collecting. The supervisor has instructed the data gatherers on how and what information they should gather from the selected data sources in order to maintain data quality. The supervisor verified each day that the data obtained were accurate and consistent. The filled-out information forms were quickly cross-checked with the source data if there seemed to be incompleteness or ambiguity in the recording.

Statistical analysis
Analyses were conducted using SPSS version 20. To demonstrate the percentages and frequencies of research variables, descriptive statistics and inferential statistics (chi-square tests) were used.
To determine the relationship between various factors, bivariate and multivariate analyses were also performed. For multivariable logistic regression, the variables that showed a statistically significant value at a p-value of 0.25 in the bivariate analysis were chosen. The Hosmer and Lemeshow test was used to determine how well the final model fit, and the results for anxiety and depression were 0.3. Multi-collinearity was also evaluated. The degree of association between variables was determined using an adjusted odds ratio with a 95% confidence interval. Statistical significance was determined by a P-value less than 0.05.

Demographic baseline characteristics
Nine hundred ninety-seven companions of ICU filled our traditional paper survey of admitted COVID-19 patients. The questionnaire was filled almost equally by both sexes, with a slight predominance for males over females (505[50.7%], 492[49.3%], respectively). Most of our sample were smokers (n = 585, 58.7%). 602 (60.4%) of the companions were of moderate economic level. At the same time, high and low economic levels represented 39.6% of the sample (9.7% (n = 97) for high economic levels and 29.9% (n = 298) for low economic levels). Non-medical companions were more than the medical ones by far (959, 96.2% were non-medicals, while only 38 companions [

Assessment of PHQ-9 & GAD-7
The resulting mean score of the depression assessment tool in our questionnaire (PHQ-9) was 9.5 (0.17, 95% CI: 9.15-9.87), ranging from 0 to 27. While the mean score of the anxiety assessment tool (GAD-7) was 9.1 (0.16, 95% CI: 8.83-9.46), ranging from 0 to 21 (Table 2).  Table 3 displays the respondent's answers to the GAD-7's seven items. The following was honestly reported as occurring for a few days, more than half the days, or almost every day by these respondents. excessive anxiety regarding several issues 81.2%); difficulty unwinding (68.8%); fear that something terrible might occur (66.9%); difficulty remaining still due to restlessness (63.3%); sensitivity to irritation or annoyance (76.2%); inability to stop or control worrying (73%); and feeling tense, anxious, or on edge (79.9%). According to our data, 19.7% of companions experienced minimum anxiety, 34.8% had mild anxiety, 29.4% had moderate anxiety, and 16.1% had severe anxiety (Fig 1). To demonstrate the correlation and quantify the  Table 5 displays the respondent's answers to the PHQ-9's nine items. The following was reported as occurring for a few days, more than half the days, or almost every day by these respondents. Feeling down (72.3%); little interest or pleasure in doing things (69%); poor appetite (60.2%); trouble concentrating on things (63.9%); and thoughts that you would be better off dead (33%). According to our data, 22.5% of companions experienced minimum depression, 26.7% had mild depression, 46.3% had moderate and moderately severe depression, and 4.5% had severe depression (Fig 2). To detect the correlation and quantify the relative impact of each independent variable on the total level of depression among the companions, a binary logistic regression analysis was conducted. The logistic regression model was statistically significant,

Discussion
In the present study, we tested for the prevalence, and the associated factors of anxiety and depression among the companions of COVID-19 patients admitted to the ICU. For anxiety, speciality and having a chronic disease were associated with the presence of anxiety in the group subjects. While other sub-groups were not associated with a significant difference in the rates of anxiety. Interestingly, companions living with the family were not associated with a significant difference in the prevalence of anxiety. On the other hand, the prevalence of depression among companions was associated with gender, occupational status, being a parent, and marital status. While smoking and working in the medical field were not associated with a statistically significant change in the prevalence of depression in the study subjects. Many studies have examined the effect of the COVID-19 pandemic on the mental health of current patients, recovered cases, and family members. Our findings align with studies held in other countries, which indicated a high prevalence of anxiety, depression, and mental health disorders in family members and caregivers of COVID-19 infected subjects [18,19]. In addition, Orsini et al. [19]. reported an increased incidence of post-traumatic stress, anxiety, and depression in parents whose children were recently diagnosed with COVID-19. They reported an association between economic damage and a higher prevalence of anxiety and depression [19]. These findings don't support our multivariate logistic regression model, which showed  that the wealth index of patients' companions was not statistical significant predictor of prevalence of anxiety. Interestingly, wealth index groups were not associated predictors for the presence of depression in our model. These data are understandable, especially in Syria, where the residents have been through 11 years of war and deterioration of the economic situation. In a recent study in Iran conducted during a COVID-19 wave in the country, the prevalence of anxiety was significantly higher among adults aged 30-40 years compared to other age groups, and that is not similar to the pattern observed in our analysis [20].
Our findings showed that females were substantially more likely to develop depression than males because females are known to have a higher prevalence of anxiety and depression disorders because inadequate mental health in women has also been linked to pressure from many social duties and overwork. Compared to males, women are also more likely to experience gender-based discrimination. They could be more likely to have mental health problems as a result. An international study investigating the factors associated with fear and psychological stress during COVID-19 in 17 countries found that females perceive more distress due to changes in employment status, being affected by the change in a financial situation, and the unsure contact with COVID-19 patients [21]. The same study has reported that people living in Syria, Palestine, and Libya, areas of war and conflict, are more associated with moderate to high psychological stress. They also reported that they observed the highest levels of coping stress among Syrian participants compared to the other countries investigated [21]. Similarly, the economic burden has been well studied as a contributing factor to psychological stress. For example, Orsini et al. reported a significant association between anxiety and depressive symptoms and caregivers of children who reported economic damage caused by the COVID-19 pandemic [19]. On the other hand, some studies reported a significant increase in psychiatric distress in young subjects with high monthly incomes. These findings aren't similar to our findings which showed a statistically significant association between economic level and the presence of both conditions. Many previous studies have reported increased anxiety and depression rates among healthcare workers during a pandemic, especially among nurses [22,23]. However, a recent meta-analysis concluded that there was no difference between health care workers and the general population in the prevalence of anxiety and depression [24]. This is inconsistent with our results, which showed a strong association between not working in the medical sector and a higher risk of developing depression. It supports the theory that people in the medical industry are more likely to be committed to taking preventative measures that lessen the severity of consequences and are thus more likely to be aware of the possible complications after COVID19. Anxiety and stress have represented a severe issue during the COVID-19 pandemic. Many interventions were proposed to decrease the burden of psychological stress on both health care workers and the general population. A study conducted on Portuguese nurses has investigated the methods and factors followed by individuals who suffered less anxiety and depression symptoms. Avoiding exposure to news related to the pandemic was significantly associated with lower rates of stress and anxiety. Maintaining social connections and verbalizing emotions were also associated with decreased incidence of anxiety and depression [25]. Another study conducted in Spain among university students has shown that relaxation techniques such as Jacobson's relaxation techniques and abdominal breathing techniques are associated with a significant decrease in the anxiety scores among these students [26].

Strengths and limitations
Due to the cross-sectional nature of this research, cause and effect relationships cannot be shown. Unfortunately, we didn't use a COVID-19-specific tool for evaluating psychological distress. For instance, the Fear of COVID-19 Scale has been determined to be a reliable tool with supporting data [27][28][29][30]. Despite the limitations noted, our findings add to the knowledge on the mental anguish experienced by COVID-19 Patient's Companions, particularly in relation to the frequently occurring mental health issues while providing medical care not only at Aleppo University Hospital but also globally. As the number of COVID-19 patients within the Omicron wave of COVID-19 has decreased, the sample size in this cross-sectional research is adequate for portraying the findings of the population of COVID-19 Patient's Companions in Syria.

Conclusion
Our study shows that almost half of the COVID19 patients' partners report moderate to severe anxiety and sadness. It is crucial to support these groups during the current outbreak (Omicron) since women, those with children, hard workers, and those who are not in the medical profession are more susceptible than others to feel anxious and sadness. Due to the COVID19 pandemic's current wave and the awful conditions in Syria after an 11-year civil war, Syrian psychological authorities and international organizations should help the people who care for COVID19 patients since many psychological symptoms have been observed among the patients and their companions.